NAVIGATING NURSING EXCELLENCE: ENHANCING CRITICAL THINKING WITH LOW-FIDELITY
SIMULATION
Introduction
Recognizing cues is the first component of the clinical judgment measurement
model. Failure to timely recognize physiological changes, escalate concerns,
and respond to clinical deterioration results in poor health outcomes. With the
current nursing shortage and implementation of student nurse
apprenticeships, it is especially important that nursing programs
integrate lessons on cue recognition and clinical deterioration.​
Two scoping reviews found nursing students lack situational awareness, often
missing cues related to vital signs, physical assessment changes, and verbal
and nonverbal cues; they perform incomplete assessments and focus on single
cues rather than the entire clinical picture (Polendna et al., 2022; Gillan et
al., 2022). Gillan et al. (2022) noted improvement in performance and
situational awareness with various simulations and repeated practice.
Orique and Phillips (2017) meta-analysis of 22 reports and 19 studies
discovered simulation experiences had a positive effect on clinical knowledge
and performance related to recognition and management of clinical
deterioration.
Preparing and Planning
The overall purpose of the simulation-based education (SBE) experience was
to develop clinical judgment skills in the ADN student entering third semester.
Objectives included:
• Recognize cues from hand-off of care reports​
• Utilize the Modified Early Warning System to determine clinical
deterioration​
• Analyze cues, prioritize hypothesis, generate solutions, formulate actions,
and evaluate outcomes with patients experiencing clinical deterioration​
Faculty developed three low-fidelity simulation cases with clinical
deterioration components that included respiratory acidosis, GI bleeding,
and hepatic encephalopathy with fluid overload. A voice-over PowerPoint on
clinical forethought and clinical deterioration was created for students to
watch as preparation for the simulation. Hand-off of care reports, medical
records, props for low-fidelity manikins, and a student worksheet based on
the National Council of State Boards of Nursing (NSCBN) Clinical Judgment
Measurement Model (CJMM) were also developed. An instructor key for pre-
briefing and debriefing was formulated.
Image retrieved from: https://whnt.com/news/huntsville/calhoun-community-college-unveils-high-tech-nursing-simulation-lab/
Eric Nappier MSN, RN, CNE, CHSE
Dr. Gina Briscoe DNP, RN, CNE
Dr. Lynnsie Mims DNP, RN, CNE
Implementation
The SBE was implemented in Summer 2021 with 93 third semester nursing students spanning
two campuses of an associate's degree of nursing program. These students were eligible to sit
for their licensed practical nursing licensure exam after completing this course.
Simulation faculty/staff set up the simulation experience in the nursing skills lab. There were
multiple stations prepared utilizing the same three SBE cases. Students were placed in groups of
6. Students then received ISHAPED (Introduction, Situation, History, Assessment, Plan, Error-
Prevention, Dialogue) report on all 3 patients. Students then assessed each patient, reviewed
client information (orders, vital signs, intake/output record, etc.) in the medical record, and
assessed vital signs. Next, students were asked to calculate a Modified Early Warning System
(MEWS) score and determine which patient was the highest priority. Students then completed
the CJMM form developed by faculty. If additional interventions were identified by the students,
an SBAR report to a faculty member was required to obtain additional orders.
Students were provided one hour to complete all tasks before a formal debriefing session.
Results
For this study, the sample size was narrowed down to 27 students from one of the institution's
campuses. A post-survey was conducted to gather qualitative data related to the student
experience. Sixteen of the twenty-seven students completed the survey. Students reported
benefit from the SBE in the development of critical thinking skills, see Figure 1. Quantitative data
was obtained by comparing HESI scores from the previous pre-intervention cohort. Critical
thinking scores on the final exam, administered as a HESI, indicated significant improvement in
critical thinking abilities, see Figure 2.
Forms
Discussion
Results of this study indicate this SBE was well received by the student
population and improved critical thinking scores as indicated by summative
testing.
This SBE could impact practice by providing experiences for undergraduate
nursing students to develop critical thinking skills related to client
deterioration. Recognizing and analyzing changes in a client's condition can
lead to better client outcomes and shorter hospital stays.
This SBE could be implemented effectively in academic settings with limited
funding. The SBE would also be beneficial in extenuating circumstances in
which internet service interruptions would not allow for high-fidelity simulator
usage.
A limitation of this study includes the inability to isolate the SBE as the only
activity affecting the increase in critical thinking HESI scores.
Image retrieved from: https://calhoun.edu/health-sciences/nursing/nursing-apprenticeship-program/
Conclusions
Low-fidelity SBE experiences may be beneficial in helping develop critical
thinking skills in undergraduate nursing students.
References
Gillan, P. C., Delaney, L. J., Tutticci, N., & Johnston, S. (2022). Factors
influencing nursing students’ ability to recognize and respond to simulated
patient deterioration: A scoping review. Nurse Education in Practice, 62,
N.PAG. https://doi-org.ezproxy.samford.edu/10.1016/j.nepr.2022.103350
Poledna, M., Gómez-Morales, A., & Hagler, D. (2022). Nursing students’ cue
recognition in educational simulation. Nurse Educator, 47(5), 283–287.
https://doi-org.ezproxy.samford.edu/10.1097/NNE.0000000000001198
Orique, S. B., & Phillips, L. J. (2018). The effectiveness of simulation on
recognizing and managing clinical deterioration: Meta-analyses. Western
Journal of Nursing Research, 40(4), 582–609. https://doi-
org.ezproxy.samford.edu/10.1177/0193945917697224